NYS Firearms License Request for Public Records Exemption
Pursuant to section 400.00 (5) (b) of the NYS Penal Law
I am: [ ] an applicant for a firearms license [ ] currently licensed to possess a firearm in NYS
Name ____________________________________________ Date of Birth_____________________
Address_________________________________________ City_________________ State________
Firearms License # (if applicable) ____________________________ Date Issued________________
Licensing Authority / County of Issuance or Application _____________________________________
I hereby request that any information concerning my firearms license application or firearms
license not be a public record. The grounds for which I believe my information should NOT be
publicly disclosed are as follows: (check all that are applicable)
[ ] 1. My life or safety may be endangered by disclosure because:
[ ] A. I am an active or retired police officer, peace officer, probation officer, parole officer, or
corrections officer;
[ ] B. I am a protected person under a currently valid order of protection;
[ ] C I am or was a witness in a criminal proceeding involving a criminal charge;
[ ] D. I am participating or previously participated as a juror in a criminal proceeding, or am or was a
member of a grand jury;
[ ] 2. My life or safety or that of my spouse, domestic partner or household member may be endangered by
disclosure for some other reason explained below: (Must be explained in item 5 below)
[ ] 3. I am a spouse, domestic partner or household member of a person identified in A, B, C or D of question 1.
(Please check any that apply)
A _____ B_____ C_____ D_____
[ ] 4. I have reason to believe that I may be subject to unwarranted harassment upon disclosure.
5. (Please provide any additional supportive information as necessary)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
I understand that false statements made herein are punishable as a class A misdemeanor. I further
understand that upon discovery that I knowingly provided any false information, I may be subject
to criminal penalties and that this request for an exemption shall become null and void.
_____________________________________________________ ________________________
Signature Date
